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The value of contemporary psychoanalysis in conceptualizing clients

By Whitney Keefner, Hilary Burt and Nicholas Grudev October 5, 2016

branding-_sigmundAs students in the University of Vermont’s graduate counseling program, our professors have stressed both the benefits and critiques of Sigmund Freud’s psychoanalytic theory. We grew curious about how Freud’s pioneering ideas have evolved over time and how they can be applied to clients today. We think that contemporary psychoanalytic theory provides a great foundation for understanding human development, and this article allowed us to explore its progression.

Freud’s psychoanalytic theory has received widespread criticism since its establishment in the late 19th century. However, Freud’s original theories have undergone numerous evolutions, resulting in the de-emphasis of antiquated ideas pertaining to psychosexual fixation and a modern emphasis on the influence of early life family dynamics on later life relational patterns. This shift from examining repressed libidinal urges to the intrapersonal/interpersonal etiology of relational patterns allows counselors to place problems into an addressable context — namely, the bolstering of intrapersonal resources (i.e., ego strength) and the formation and maintenance of quality attachment relationships. These two branches of psychoanalytic thought are known respectively as ego psychology and object relations.

Ego psychology

From a contemporary psychoanalytic perspective, an individual’s mental health is dependent on the regulatory abilities of the ego. The ego is the contemporary psychoanalytic term for the psychological mechanism that governs the processing of reality and the regulation of instinctual urges and moral rigidity. The ego has many significant roles, including perceiving and adapting to reality, maintaining behavioral control over the id and defending the individual from undue anxiety. The undeveloped (or overstressed) ego can lead to a wide span of threats to a person’s wellness.

Mental health issues arise when the ego has not developed properly and its regulatory functions are either immature or absent. The Psychodynamic Diagnostic Manual (a psychoanalytic “companion” to the Diagnostic and Statistical Manual of Mental Disorders that is used by many practitioners of contemporary psychoanalytic theory) outlines several functions of ego health. These functions (collectively referred to in the Psychodynamic Diagnostic Manual as the Personality Axis, or P Axis) include:

  • The maintenance of a realistic and stable view of self and others
  • The ability to maintain stable relationships
  • The ability to experience and regulate a full range of emotions
  • The ability to integrate a regulated sense of morality into day-to-day life

Counselors might use these functions collectively as a guide to conceptualize the health of a client’s ego, while simultaneously considering specific aspects of ego function as possible starting points for counseling interventions. It is also worth considering how clients may defend their sense of self through the use of defense mechanisms.

Considering ego and relationships: Object relations

Whereas ego psychology represents contemporary psychoanalytic views on the development and regulation of the self, a separate yet related branch of contemporary psychoanalysis focuses on the self in relationship with others. Many theorists within the psychoanalytic school of thought place significant emphasis on the association between intrapersonal and interpersonal wellness.

From an object relations perspective, counselors may view barriers to client wellness as stemming from the quality of early interactions between the client and his or her caregivers and how the client internalized these early relational experiences. When an infant is first born, it is undifferentiated from the mother. Thus, the self has not yet formed. The self is composed of the ego, the internal objects (i.e., structures formed due to early experiences with a caretaker) and the affect that binds the ego and internal objects together.

The development of internal objects and ego is crucial to one’s functioning in later life because impaired object relations may result in the development of abnormal behaviors, cognitions or emotions. To elaborate, when an individual experiences negative relational experiences in the caretaker-child dyad, healthy object relations fail to formulate. These relational blunders occur after ego-relatedness (i.e., the phase of absolute dependence on the mother). When the child is not provided with an ego-supportive environment, growth of the ego is inhibited.

Fragmented ego strength during childhood may contribute to later issues in adulthood. Object relations bears a strong theoretical resemblance to attachment theory in that the relational experience between a caretaker and an infant carries implications for functioning across the life span. For example, the relationships that individuals hold with others (caregivers, friends, romantic partners, etc.) shape the development and regulatory ability of the ego. Individuals with fragmented ego strength are therefore at a disadvantage because they developed a faulty foundation for both self-regulatory abilities and social interactions later in life.

Defense mechanisms

In her book Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process (2011), Nancy McWilliams conceptualizes a person’s capacity to acknowledge reality — even when that reality is unpleasant — in terms of ego strength. Ego strength, like other aspects of wellness, is constantly in flux and can be eroded temporarily by the stresses of day-to-day life. When ego strength is compromised by anxiety-provoking circumstances, or even by mental fatigue (we note, for example, that our egos begin to feel considerably less sturdy by the end of the semester), ego defense mechanisms serve as a kind of respite from perceived threats. When sensitive topics are broached in the context of counseling, client defense mechanisms may present themselves. Because these same defenses likely arise in other contexts that are interpersonally challenging for clients, acknowledging and discussing these defensive processes may prove to be a generative pathway to change.

According to McWilliams, when clients use a defense mechanism, they are generally trying unconsciously to avoid the management of some powerful, threatening feeling (e.g., anxiety, grief, shame, envy). In the same way that fabled knights used shields to deflect the fiery breath of a dragon, clients may use defense mechanisms to ward off potential threats while attempting to maintain safety and stability in their stances.

It is important to note that the use of defense mechanisms is a common, if not daily, occurrence in the lives of most people. Indeed, the use of defense mechanisms is considered by most mental health professionals to be adaptive and necessary for sound mental health. George Vaillant (1994) described how defense mechanisms help people to regulate internal and external reality, and decrease conflict and cognitive dissonance. However, it is also important to note that defense mechanisms can be used in ways that are more adaptive or less adaptive. The degree to which an architecture of defenses might be considered adaptive pertains to the frequency and rigidity with which the defenses are used and the types of defenses employed.

In broad terms, defense mechanisms might be defined as primary or secondary defensive processes. McWilliams considers primary defenses to be less adaptive because they contain a greater degree of distortion in the boundary between the self and the outer world relative to secondary defenses. Primary defense mechanisms are characterized by the avoidance or radical distortion of disturbing facts of life.

For example, McWilliams explains how the primary defense mechanism of introjection involves substituting the perceived qualities, values, behaviors or beliefs of another person for one’s own identity. In effect, these individuals are uncritically adopting the attitudes, values or feelings that they perceive a valued other wants them to have. McWilliams suggests that such global distortions of self and reality likely have their origins in early developmental stress and the lack of developmental opportunities to cultivate a coherent and stable ego or a differentiated sense of self.

McWilliams considers secondary defenses to be “more mature” because they allow an uncompromised sense of self to remain relatively intact, even as an uncomfortable reality is held at bay. Secondary defenses allow for greater accommodation of reality and a stable sense of self. For example, counseling students may occasionally employ “gallows humor” (humor is one of numerous secondary defenses that McWilliams describes) before taking tests such as the National Counselor Examination. Humor in such cases helps to ease the tension by distracting from the reality of the situation without engaging in significant denial or distortion of the situation itself.

The degree to which developmental opportunities have allowed for the establishment of the aforementioned ego domains and the type of defensive architecture generally used (i.e., primary vs. secondary) contribute significantly to how clients perceive difficulties in their lives.

Ego dystonic vs. ego syntonic

An essential aspect of understanding an individual’s mental health is the presence or absence of an observing ego. According to McWilliams, an observing ego enables clients to see their problems as inconsistent with the other parts of their personalities. Such problems are termed ego dystonic. In terms of counseling individuals with ego dystonic problems, the client’s and the therapist’s understanding of the problems are likely to align because both parties recognize the problems to be undesirable. Thus, the observing ego allows for identification of unwanted problems and helps the client bring his or her personality back to a desirable level of functioning.

Problems that are unrecognizable by an individual are termed ego syntonic. According to McWilliams, such problems are likely to be rooted deep in the individual’s personality and often develop during early childhood. Because ego syntonic problems are intertwined in the person’s character, addressing these problems can be perceived to be a direct assault on the individual’s personality.

Taking away an adult representation of an adaptation from childhood could compromise an individual’s entire way of being. It is therefore important for counselors to handle ego syntonic problems slowly and delicately. For example, counselors could validate and empathize with a client’s ego syntonic experience while subsequently offering an alternative perspective. Establishing rapport and trust in the counseling relationship is perhaps the strongest tool when working with individuals whose maladaptive behaviors are intertwined in their personalities.

Substantial time is required for ego syntonic problems to become ego dystonic, and treatment is not possible until an individual can recognize his or her problems as such. The presence or absence of an observing ego determines whether an individual’s problems are neurotic or entwined in his or her character. Ego syntonic problems are telling of a dysregulated ego because the ego lacks the ability to acknowledge, understand and accept reality. Individuals who are capable of recognizing their problems likely have a better sense of self and a more developed ego.

Summary

Contemporary psychoanalytic thought emphasizes the impact of the ego on an individual’s well-being. Whether development is viewed from an object relations lens or an ego psychological lens, the ego is at the core of healthy development. The ego’s ability to balance the id and the superego, and process reality and emotions, can be learned only if an individual’s social relationships throughout his or her lifetime foster healthy ego development. Unhealthy development or underdevelopment of the ego can cause psychopathological problems because an individual’s abilities to process reality and emotions are likely to be impaired.

According to McWilliams, all of us have powerful childhood fears and yearnings. We handle them with the best defense strategies available to us at the time and maintain these methods of coping as other demands replace the early scenarios of our lives. Thus, defense mechanisms are useful in protecting the ego, but when used in excess, they may cause psychopathological problems. In this way, ego defense mechanisms are like sugar. When needed, sugar provides valuable energy that prevents the body’s systems from malfunctioning. But when consumed in excess, sugar can cause disease and negatively affect an individual’s well-being.

Conceptualizing clients through a contemporary psychoanalytic lens can provide counselors with a deep understanding of the past and present factors that are shaping clients’ lives. This approach illuminates how adaptations formed during childhood can present as maladaptive behaviors or cognitions in adulthood. Unlike classic psychoanalysis, contemporary psychoanalytic theory considers the social factors that contribute to ego health, therefore giving counselors a more comprehensive and applicable understanding of the client.

 

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The authors would like to extend a special thank you to Aaron Kindsvatter for his contributions and supervision.

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Whitney Keefner is a second-year student pursuing a dual master’s degree in clinical mental health counseling and school counseling at the University of Vermont. She is currently interning at Spectrum Youth and Family Services in Burlington, providing integrated co-occurring treatment for mental health and substance abuse issues. Upon completing her degree, she hopes to continue working with individuals struggling with substance abuse in a community mental health setting. Contact her at wkeefner@uvm.edu.

Hilary Burt is a second-year graduate student in clinical mental health counseling at the University of Vermont. She is interning at UVM Counseling and Psychiatry Services. After she completes her degree, she hopes to work with children and adolescents in a community mental health setting. Contact her at hburt@uvm.edu.

Nicholas Grudev is a second-year graduate student interning at the MindBody Clinic at the University of Vermont Medical Center. Upon completing his master’s degree, he plans to enroll in a doctoral program to study counseling psychology. Contact him at ngrudev@uvm.edu.

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